MANAGEMENT OF CROSSBITE

Submitted by:
HARIHARAN MOOSAD V
Final year part 1
CDC

Guided by:
Dr. Kesav Raj
Dr. Mithun
Dr. Ajeesha
Dr. Aslam
Dr. Fasila
 crossbite
CONTENTS
 Introduction
 Definition
 Classification
 Skeletal crossbite
 Dental crossbite
 Functional crossbite
 Anterior crossbite
definition
etiology
diagnosis
mangement
 Posterior crossbite
etiology
diagnosis
management
 Surgical correction
INTRODUCTION
 In normal occlusion, there is overlap of maxillary teeth over
the mandibular teeth.
 In the anterior segment, there is vertical as well as horizontal
overlap of maxillary teeth over mandibular teeth.
 The vertical overlap is ‘overbite’ & horizontal overlap is
‘overjet’.
 In posterior segment, the maxillary buccal cusp overlap over
mandibular buccal cusp. The mandibular buccal cusp occlude
in the central fossa of maxillary teeth.
 Likewise, maxillary palatal cusp occlude with the central
fossa of the mandibular teeth.
 DEFINITION
 Cross bite is a term used to describe abnormal occlusion in the
transverse plane the term is also used to describe reverse overjet of one
or more anterior teeth.
 The term describe the reverse overjet of one or more anterior teeth
usually expressed in anterioposterior (labiolingual) direction.
 According to Graber ‘Cross bite’ is a condition where one or more may
be malpositioned abnormally- buccally/ labially or lingually with
reference to apposing tooth or teeth.
 According to American Association of Orthodontists Glossary “An
abnormal relationship of teeth or tooth to the opposing teeth, in which
normal buccolingual or labiolingual relationship are reversed.
Classification of Cross Bite
 Based on the Nature of position

• Anterior Cross Bite

• Posterior Cross Bite

Anterior Cross Bite

• Single Tooth Cross Bite
• Segmental Tooth Cross Bite
Posterior Cross Bite
 Unilateral
 Bilateral
 Based on Etiology and Anatomic Location

 Skeletal Cross Bite

 Dental Cross Bite
 Functional Cross Bite
 According to number of teeth involved
 Single tooth crossbite
 Segmental tooth crossbite
 According to existence on one/both sides of arch
 Unilateral
 Bilateral.
Skeletal Cross Bite

 Skeletal Cross Bite is associated with a discrepancy in the size

of the maxilla and mandible basal skeleton.
 Narrow Upper Arch →Posterior Cross Bite
 Usually inherited & Developmental in origin
 Results from hormonal disturbance
 Either present in interior or posterior segment
 Result of retarded maxillary growth or maxilla backwardly
placed.
2.Dental Cross Bite

 Dental Cross Bite are generally localized in nature with one or

more teeth in one teeth are abnormally related to that of
opposing arch.
 Lingual eruption path of the maxillary anterior
 Trauma to the deciduous dentition in which there is
displacement of tooth buds.
 Delayed eruption of deciduous dentition and super numeracy
teeth.
 Tooth material arch length discrepancies can result in crowding
and lingual positioning of upper teeth leading to a dental Cross
Bite.
 Functional Cross Bite

 It caused by an occlusal interference that requires the mandible

to shift either anteriorly or laterally during Jaw closure in order
to achieve maximum occlusion.
 An acquired muscular reflex pattern during closure of the
mandible is involved in functional Cross Bites.
 Results from the mandibular shifting into an abnormal but often
more comfortable position→ this can present as a Unilateral
Posterior Cross Bite
Anterior Cross Bite
Defnition; Anterior Cross Bite is defined as malocclusion
resulting from the lingual position of one or more of the maxillary
anterior teeth in relationship with the mandibular anterior teeth
when the tooth are in centric relation occlusion.

Etiology
1.Anterior Skeletal Cross Bite

 Retarded development of maxilla ie: Retarded development of

maxilla in sagittal as well as transverse direction can cause Cross Bites
in the anterior or posterior region. This is seen in
 genetic & developmental disorders such as craniofacial
diagnosis, cleidocranial dysplasia, achondroplasia cleft-palate,
congenital syphilis, down syndrome.

 Collapse of maxillary arch as seen in congenital defects such

as cleft of palate.

 Over development of mandible→ Craniofacial dysplasia

 Hormonal disturbances→ Aromegaly & Gigantism.

 Unilateral hypo or hypo-plastic growth of any of the jaws can

cause Cross Bites
2. Anterior Dental Cross Bites

 Trauma to the deciduous dentition in which there is

displacement of permanent tooth buds.

 Prolonged retained deciduous tooth may defect its erupting

successor in a palatal direction and may result in single tooth
interior Cross Bite.

 Arch length tooth material discrepancies can result in

development of crowding and defect one or more teeth leading
to dental Cross Bites.

 Missing of permanent tooth especially the upper lateral incisor

may sometimes result in anterior segment Cross Bite
FEATURES
 Skeletal Anterior Cross Bites are charectorized by concave
profile as seen in class iii skeletal conditions.
 Asymmetry of the face can be seen in unilateral cross bites
Intra-oral Features:
 Reverse overjet
 Stripping of gingiva
 Loosening of teeth
 Abnormal abrasion of teeth
 Diagnosis
1. Routine clinical Examination
Careful examination of models and cephalmetric analysis
To determine the nature of Cross Bite, whether skeletal, dental
or functional..
Presence of occlusal interference & functional shifts.
2. Functional shift,
Whether a fuctional shift exists between centric relation
and centric occlusion.
3. Presence of dental compensation
Management of Anterior Cross Bites
 Primary Dentition Stage:
Anterior Cross Bite when noticed can be resolved by removing the
interferences by occlusal grinding or by extracting the primary incisor
which are in Cross Bite relation.

 Mixed Dentition Period:

Maxillary lateral incisors bind to erupt lingually and may be tapped if
there is no enough space. In such cases, extracting the primary canine
prior to complete eruption of lateral incisor leads to spontaneous
correction of Cross Bite.
.
 If sufficient space is available a maxillary removable appliance is the
best mechanism to correct anterior cross Bite that requires tipping
movement.developing crossbite can be treated with tongue blade
therapy or catalans applaince therapy.

• Permanent dentition period

Fixed applainces can be given to correct anterior crossbites if the
reverse overjet is not more than 1-2 mm.
Applainces and methods include
1.Tongue blade therapy
 It is used in developing single tooth anterior cross bite prior to
complete eruption. There should be sufficient space in the arch to
accommodate the tooth in cross bite after resolving the crossbites.
 The tongue blade is a flat wooden stick or metal object resembling
an ice cream stick. One end of it is placed inside the mouth,
contacting the palatal aspect of the upper tooth that is in cross
bite. The blade is made to rest on the mandibular tooth that is in
cross bite which acts as a fulcrum. The patient is asked to apply
force downwards and backwards of the free end so that the oral
part of the blade behind the palatal aspect of upper teeth exerts
force in upward and forward direction..
 This action thrusts the upper teeth I forward direction and
relieves it from the cross bite
 The patient is asked to do this exercise for a total period of 1-2
hours for about 10-14 days by which time the tooth will be
pushed out. Thus most of the developing cross bites if recognized
at an early stage by the dentist can be resolved by this simple
tongue blade therapy
2. Catalan’s appliance or lower anterior inclined
plan
It is used to intercept the fully developed cross bite of
single tooth of the upper arch that is of recent origin.
 The inclined planes are usually made of acrylic but can
also be fabricated with cast metal.
They are concerned onto the lower anterior teeth.
The inclined plane is designed to have a 45°angulation to
the long axis of the lower anterior.
Whenever the maxillary tooth in cross bite touches the
inclined plane, a forward directed force moves the tooth
to a more labial position.
The steeper the angle more the force generated.
 It is also indicated in cased where adequate space exists in the arch
for alignment of the maxillary teeth that are in cross bite.
 They are to be selectively used only in those cases of anterior
crossbite which have resulted from palatally displaced maxillary
incisor but not due to that of labially tipped mandibular anterior
tooth.
 The Catalan’s appliance should not be placed for more than six
weeks, otherwise it may lead to open bite.
3.Use of double cantilever spring(z spring)
 A double cantilever spring can be used to push labial one or
two maxillary anterior teeth that are in crossbite.
 However there should be adequate space in the arch to
accommodate the corrected position of the teeth that were in
crossbite.
 A flapper spring can also be used to correct single tooth
crossbite.
 A posterior bite plane is incorporated to relieve the locking
of the teeth that are in cross bite.
4.Acrylic Plates with Screws:
A split acrylic plate with screw incorporated can be used to
treat anterior crossbites.
5.Fixed corrective appliances for treatment of anterior
crossbite:
Dental anterior crossbite involving one or two teeth can be
treated with fixed appliances using multi-looped arch wires.
Management of Anterior Skeletal
Cross bites
1.Mixed Dentition Period:
 Treatement of skeletal anterior crossbite during growth period
takes the advantage of growth modulation procedures .
 Cephalometric analysis should be carried out to locate the
skeletal problem
 Anterior cross bite that occurs as a result of a retropositioned
maxilla should be treatedwith protraction face-mask or reverse-
pull headgear.
 These facemasks help in protraction of the maxilla thereby
normalizing skeletal crossbite. Excessive mandibular growth
leading to skeletal anterior crossbites can be intercepted by use
of chin cap.
2.Permanent Dentition Period
 The skeletal anterior crossbites can be treated by camouflage by
masking the skeletal effects
3.Post Permanent Dentition
 Comprehensive appliance therapy and/ or surgical correction
are required.
 Anterior Crossbite in
Centric occlusion
TREATMENT
PLAN : Evaluate in Centric relation

Class I molar and caninerelation with Class I molar and canine Class III molar and canine relation
only incisors in crossbite relation incisors can be with negative overjet
brought edge to edge

Class I malocclusion with

only dental crossbites Pseudo-Class III malocclusion

Remove occlusal True Class III skeletal

interferences malocclusion
Primary Remove interferrences

No active treatment advised Primary

Corrected
Interception by tongue blade therapy/
correction by Catalan’s appliance,
Mixed removable appliance with cantilever Interception by reverse
Mixed
spring or fixed appliance in severe facemark/chin cap theory
cases

Camouflage by masking the

skeletal effects Permanent
Fixed comprehensive
Permanent therapy with biteplanes
relieving the occlusion
Orthognathic surgery Post
permanent
 Othognathic surgery for correction of anterior
skeletal crossbites
1.Le fort osteotomy and advancement for maxillary
retrognathism
2.Orthognathic maxilla and mandible
3.Bilateral sagittal split osteotomy and set back for correction
of mandibular prognathism.
Posterior Crossbite
Defnition
Posterior Crossbite refers to an abnormal transverse
relationship between the maxillary and mandibular posterior
teeth.
Some common terminology is given below
 Telescopic bite or scissors bite or Buccal non-
occlusion:
 Lingual Non-occlusion
 Complete Maxillary Buccal Crossbite
 Complete Maxillary Palatal Crossbite:
Etiology
Posterior Skeletal Crossbite:
 Skeletal Posterior crossbite is the resulf of the lateral
discrepancy between upper and lower teeth as a result of a
discrepancy between the apical bony bases.
 Posterior crossbites are usually characterized by a narrow
maxillary arch. Posterior skeletal crossbites are usually bilateral
in origin.
 The causes may be:
 Retarded development of maxilla as described earlier for anterior
crossbite.
 Collapse of maxillary arch as seen in congenital defects such as clefts of
the palate.
 Overdevelopment of mandible due to hormonal and
developmental disturbances.
 Unilateral hypo-or hyperplastic growth of any of the jaws can
cause true unilateral crossbite. This may result from trauma,
ankylosis or infection in the TMJ.
 Transverse skeletal crossbites are seen in narrow upper arch
resulting from decreased growth stimulation in the mid-palatal
suture.
 Sagittal discrepancies of the jaws such as a forwardly positioned
mandible results in the wider part of the mandibular arch
occluding with a narrower part of the maxillary arch leading to
transverse of posterior crossbites.
 Abnormal oral habits: Presence of abnormal oral habits such
as thumb sucking and mouth breathing can cause lowered
tongue position. Thus the tongue no longer exerts outward
thrust to balance the inward forces exerted on the teeth by
the buccal group of musculature.
 This inbalance between the external and internal muscle
forces can result in narrowing of the upper arch leading to
posterior crossbite.
Posterior Dental Crossbites
 Prolonged retention of a deciduous tooth often results in palatal
deflection of its erupting successor causing single tooth
posterior crossbite.
 Crowding and abnormal displacement of one or more teeth as a
result of arch length-tooth material discrepancies may cause
dental crossbite, particularly the upper canines and lower
second pre-molars.
Posterior skeletal crossbite

Skeletal Crossbites

Unilateral Fuctional Shift Bilateral

False or apparent
True True
unilateral
Diagnosis:
Carefull examination of models and cephalometric analysis
should localize the problem. Examination should include the
following:
 Evaluation of facial proportion and symmetry
 Evaluation of intra-arch malaignment and symmetry of jaws
 Presence of occlusal interferences and functional shifts
 To determine the nature of the crossbite whether skeletal,
dental or functional
 Evaluation of skeletal and dental relationship in the transverse
plane of space.
Management of posterior Dental
Crossbite.
Primary dentition period:
 Posterior crossbite in primary dentition is usually as a result of
constriction of the maxillary arch which often results from an active
digit or pacifier habit.
 . Determine whether there is an associated mandibular shift.
 Treatment is implemented if mandibular shift is present. Some
authors believe that unilateral posterior crossbites with functional
shift should be treated in the primary dentition to prevent
asymmetric positioning of the condyles and asymmetric growth.
 If the intermolar width is satisfactory, grinding of primary canines is
done to eliminate deflective contact.
 If both molar and canine width are narrow, expansion of the upper
arch is indicated.
 True Unilateral Posterior Crossbite
This is present in skeletal asymmetry
A true unilateral crossbite occurs when
the patient exhibits no lateral functional
shift of the mandible during closure from
centric relation (CR) into centric
occlusion (CO)
In true unilateral posterior crossbites,
lower dental midline deviated away from
the upper dental midline towards the side
of the crossbite on opening of the
mandible
True bilateral Posterior Crossbite
This is present in skeletal symmetry
Most patients with a posterior bilateral
crossbit do exhibit some CR-CO lateral
functional shift upon closure of the
mandible and produces apparent
unilateral crossbite
One important diagnostic feature of
unilateral posterior crossbites resulting
from bilateral maxillary constriction
and a functional shift is that they
typically have a midline discrepancy in
centric occlusion with lower dental
midline toward the side with the
crossbite. Lower dental midline is
usually coincident with that of the
upper dental midline on opening of the
mandible.
Mixed dentition period:
 Posterior crossbite correction in mixed dentition can be
difficult and confusing. The three basic approaches to the
treatment of posterior dental crossbite in mixed dentition
period are:
 Equilibration of occlusion to eliminate mandibular shift
 Expansion of the constricted maxillary arch
 Repositioning of individual teeth to deal with intra-arch asymmetries
Permanent Dentition Period:
 Dental crossbites of single tooth can be effectively corrected
by crossbite elastics.
 Posterior dental crossbites of entire segment are corrected by
removable or fixed springs like coffin spring, Quad helix, W-
arch.
 Slow maxillary (palatal) expansion can be utilized to correct
the dental crossbites. Mild arch expansion in the posterior
segment can be obtained by corrective fixed appliances.
 Appliances and Methods used in treatment of
Posterior Dental Crossbite
1.Crossbite Elastics:
Single tooth crossbites that commonly involve the molars
can be treated using cross elastics. These are stretched
through the occlusal suface between the palatal surface of
maxillary tooth and the buccal surface of mandibular
tooth that are in crossbite. There should be sufficient
space in the arch for their alignment. The elastics are
worn continuously day and night for effective correction.
The treatment should not be continued for more than six
weeks as the elastics can extrude the teeth.
2.Coffin Spring:
It is a removable appliance capable of slow dent alveolar
expansion. It is an ideal appliance to treat unilateral
crossbites during mixed dentition stage. Coffin spring is
believed to bring about dento alveolar expansion. However
use of this appliancein younger patients is believed to bring
about some amount of skeletal expansion. It has an
advantage over screw appliances in that differential
expansion can be obtained in the premolar and molar
regions
3. W-arch Expansion Appliance (Porter’s Appliance):
The Preferred appliances for the correction of bilateral posterior
crossbites in pre-adolescent child are W-arch appliances and quad helix
appliance the W-arch or Porter’s appliance is a type of a fixed mechanical
appliance. It brings about both dental and skeletal changes. It can be
modified to be used as a removable appliance. Usually 2-3 months of
active treatment followed by retention for 2 months is required.
4. Quad Helix:
It is made up of 38 mil wire. It is more flexible than W-arch and has
more springiness and range of action. The quad helix is capable of dento
alveolar expansion of the molar as well as premolar region. It can bring
about skeletal expansion when used in younger patients.
5. Hyrax Appliance: indicate in rapid palatal expansion.
6. Removable Plates:
 Unilateral crossbites can be treated using removable appliances.
 These appliances basically consist of an acrylic plate that is split and
connected by a jack screw similar to an expansion plate.
 It is retained with the help of Adam’s clasps.
 A labial bow can also be incorporated into the appliance for minor
space closure and retraction.
 The plate is bi-sectioned into a small segment and larger segment. The two
segments are connected by one or more jack screws. The smaller segment lies
proximal to the area in crossbite whereas the larger segment is used for anchorage.
7. Arch expansion using fixed applaince
 Unilateral crossbite can be achieved in a patient who is undergoing fixed
mechanotherapy. mild expansion can be brought about by using expanded arch
wires
8. Retention
 Treatment of anterior cross bite does not require any specific retention
appliances.
 The mandibular anterior teeth act as natural stops and prevents the
relapse of maxillary anteriors into crossbite.
 The posterior crossbite by expansion devices requires the retention for
2-3 months with same appliance.
 CONCLUSION
 Diagnosis is the golden key to success. A case of crossbite can
be deceptive. So it is always mandatory to think before we leap
into conclusion. Whether it is crossbite of a true,nature or
pseudo. To achieve better treatment finish,crossbite should be
dealt as soon as detected &the choice of armamentarium can be
left to clinicians discretion.
Referance
1.Textbook of Orthodontics – S Gowri Shankar -1st edition
2.Orthodontics –The art & science-Bhalaji-7th edition